A Case of Combined Percutaneous Transfemoral Mitral Valvuloplasty and Aortic Valve Implantation

ABSTRACT: We present the case of an 83-year-old man who was admitted with New York Heart Association class III dyspnea and paroxysmal nocturnal dyspnea. Because of high surgical risk, a percutaneous treatment of both mitral and aortic valvulopathies was planned. This case reports the feasibility of a totally percutaneous approach in combined rheumatic mitral and aortic valve disease for patients with prohibitive surgical risk.

J INVASIVE CARDIOL 2011;23:E200–E201

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Case Report. An 83-year-old man was admitted to our department for dyspnea (New York Heart Association class III) and paroxysmal nocturnal dyspnea. The patient had persistent atrial fibrillation, cerebrovascular disease, and severe restrictive pulmonary disease. Transthoracic echocardiogram showed a rheumatic disease with severe mitral stenosis (mitral valve area of 1.0 cm², maximum gradient of 39 mmHg, mean of 13 mmHg) and mild mitral regurgitation and severe aortic stenosis with moderate aortic regurgitation (maximum transvalvular aortic gradient of 110 mmHg, mean of 66 mmHg, aortic valve area of 0.8 cm²). Systolic pulmonary pressure was 95 mmHg at cardiac catheterization (mean of 52 mmHg) and mean wedge pressure was 28 mmHg. Left ventricular ejection fraction was 60%. At transesophageal echocardiogram, the Wilkins score was 10 and the aortic annulus was 22 mm. Because of high surgical risk (logistic EuroSCORE of 32% and STS score of 10%), a percutaneous treatment of both mitral and aortic valvulopathies was planned. We decided to perform the mitral balloon valvuloplasty first to reduce the pulmonary pressure and to increase the cardiac output and thus to improve the safety of transcatheter aortic valve implantation (TAVI). Moreover, because the patient was unquestionably refused even for back-up surgery, we preferred to make sure that the mitral valvuloplasty was successful before proceeding with the TAVI. We aimed to avoid wasting a costly prosthesis because of mitral valvuloplasty failure. The mitral balloon valvuloplasty was performed with antegrade transseptal approach. By progressive inflations of a 28 mm Inoue balloon catheter (Toray Industries Inc., Tokyo, Japan), transvalvular mitral gradient dropped from 15 mmHg to 7 mmHg, and the valve area improved either at invasive (1.5 cm²) or at transthoracic echo evaluation (1.6 cm²) with moderate regurgitation (Figure 1).

Two weeks later, after a 23 mm balloon aortic valvuloplasty, a 26 mm Edwards Sapien XT transfemoral device (Edwards Lifesciences, Irvine, California) was successfully deployed across the aortic valve (Figure 2). Aortic angiography showed only a mild paravalvular leak. The patient was discharged at day 12 in New York Heart Association class I and dispatched to cardiac rehabilitation.

This case reports the feasibility of a totally percutaneous approach in combined rheumatic mitral and aortic valve disease for patients with prohibitive surgical risk.

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From the ^*Cardiology and ^†Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 24, 2010, provisional acceptance given December 17, 2010, final version accepted January 10, 2011.
Address for correspondence: Giuseppe Tarantini, MD, PhD, Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, Policlinico Universitario, 2 via Giustiniani, 35128 Padova, Italy. Email: giuseppe.tarantini.1@unipd.it